The CHEER trial that showed that patients with refractory VF cardiac arrest who previously would have been pronounced dead in the field can survive with a good neurological outcome if they receive effective circulatory support and definitive intervention in hospital. This suggests that we need to rethink our approach to resuscitation to consider whether we can make CPR more effective to improve the chance getting our patients to definitive care while still potentially viable when defibrillation has been unsuccessful. This is the thought that led to the proposal recently published in Resuscitation that the resuscitative endovascular balloon occlusion of the aorta (REBOA) technique could be useful in prehospital medical cardiac arrest. By occluding circulation to non-vital areas of the body and improving perfusion to the heart and brain, it may someday play a role in the treatment of refractory cardiac arrest.

There are barriers to seeing this idea implemented, even if the intended physiological impact is seen. These are primarily technical challenges having to do with the need to achieve femoral artery access for endovascular occlusion of the aorta, which to our knowledge has not yet been done during cardiac arrest. Widespread use of the technique would also be limited by the need to have practitioners in the field who are competent in the technique and perform it frequently enough to maintain the skill.

Despite these challenges, this novel resuscitation strategy is worth exploring further to determine feasibility, later to be followed by an assessment of efficacy if it is found to be technically feasible. Please read the full letter and share your thoughts in the comments below.

2 thoughts on “Is there a place for REBOA in cardiac arrest?”

I think certainly the animal data is very compelling, and as you say shows great improvement in cardio-cerebral perfusion in those models. I think as catheter technology evolves, and as we recently discussed in our paper (http://www.resuscitationjournal.com/article/S0300-9572(15)00398-6/abstract), REBOA will have a place in non-traumatic arrest potentially as a bridge to ECMO or other techniques. I think what will be particularly fascinating is the evolution of work by people like Dr Jim Manning on selective aortic arch perfusion (SAAP) and incorporating that into cardiac arrest algorithms. The future is very exciting!

You mention in your piece the technical aspects of femoral access. I think this is a critical point, and certainly with the currently used equipment in North America, this emphasizes the great importance of appropriate training. The technology here is evolving and will soon allow the use of smaller sheaths and catheters, but this is still a little ways away. Internationally however they are already using smaller sheaths, and we can certainly all learn from their experience.

Additionally, although REBOA placement in arrest in the prehospital setting has not yet been reported (or to my knowledge been done), we have done it in hospital in traumatic cardiac arrest. In the arrest state, the artery is primarily accessed via a groin cutdown technique, although ultrasound can also be utilized.

Thank you very much for your comments and for sharing a link to your review, Dr. Qasim. The future certainly is exciting! Did you experience any unexpected challenges in using the REBOA in your patient in traumatic cardiac arrest?

Anuar and I have also not yet heard of a case of REBOA placement in a patient in cardiac arrest in the prehospital setting but we are interested in the possibility of this taking place. It seemed like our European colleagues might be the best situated for this with their more widespread use of critical care physicians in the field than we generally have in North America. Do you anticipate that there might be an American EMS system where there is direct field involvement of physicians who would be able to apply this technique for a patient in medical cardiac arrest?